Basic Information
| Provider Information | |||||||||
| NPI: | 1467506428 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. MARGARET MERCY HEALTHCARE CENTERS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. MARGARET MERCY ANESTHESIA SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463110800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002221442 | ||||||||
| FaxNumber: | 5177877122 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 JOLIET ST | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199332270 | ||||||||
| FaxNumber: | 2198522515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 06/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | GRYZBEK | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2199322300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 200424790B | 05 | IN | MEDICAID |